=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821209537
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRAIG COUNTY MEDICAL SERVICE CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 821 N FOREMAN ST
-----------------------------------------------------
City | VINITA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74301-1434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-256-7856
-----------------------------------------------------
Fax | 918-256-7857
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 821 N FOREMAN ST
-----------------------------------------------------
City | VINITA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74301-1434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-256-7856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CATHERINE HANEGAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 918-744-3525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL1802
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------